PART THREE - The Full Text of the Standards of Care
V. The Treatment of Adolescents
Adolescents should be dealt with conservatively because gender identity development can rapidly and unexpectedly evolve. They should be followed, provided psychotherapeutic support, educated about gender options, and encouraged to pay attention to other aspects of their social, intellectual, vocational, and interpersonal development. Because an adolescent shift toward gender conformity can occur primarily to please the family, it may not persist or reflect a permanent change in gender identity. Clinical follow-up is encouraged.
Adolescents may be eligible for beginning triadic therapy as early as age 18, preferably with parental consent. Parental consent presumes a good working relationship between the mental health professional and the parents, so that they, too, fully understand the nature of the GID. In many European countries 16 to18 year-olds are legal adults for medical decision making, and do not require parental consent.
The age at which adolescents who consistently maintain an unwavering desire to live permanently in the opposite gender role should be permitted to begin the real life experience or hormonal therapy is 18 years.
Hormonal Therapy for Adolescents. Hormonal treatment should be conducted in two phases only after puberty is well established. In the initial phase biological males should be provided an antiandrogen (which neutralize testosterone effects only) or an LHRH agonist (which stops the production of testosterone only), and biological females should be administered sufficient androgens, progestins, or LHRH agonists (which stops the production of estradiol, estrone, and progesterone) to stop menstruation. After these changes have occurred and the adolescent's mental health remains stable, biologic males may be given estrogenic agents and biologic females may be given higher masculinizing doses of androgens. Medications used in the second phase, estrogenic agents for biologic males and high dose androgens for biologic females, produce irreversible changes.
Prior to Age 18. In selected cases, the real life experience can begin at age 16, with or without first phase hormones.
The administration of hormones to adolescents younger than age 18 should rarely be done. These first phase therapies to delay the somatic changes of puberty are best carried out in specialized treatment centers under supervision of, or in consultation with, an endocrinologist, and preferably, a pediatric endocrinologist, who is part of an interdisciplinary team. Two goals justify this intervention: a) to gain time to further explore the gender and other developmental issues in psychotherapy; b) make passing easier if the adolescent continues to pursue gender change. In order to provide puberty delaying hormones to a person less than age 18, the following criteria must be met:
(1) throughout childhood they have demonstrated an intense pattern of cross-gender identity and aversion to expected gender role behaviors;
(2) gender discomfort has significantly increased with the onset of puberty;
(3) their social, intellectual, psychological, and interpersonal development are limited as a consequence of their GID;
(4) serious psychopathology, except as a consequence of the GID, is absent;
(5) the family consents and participates in the triadic therapy.
Prior to Age 16. Second phase hormones–those which induce opposite sex body should not be given prior to age 16 years.
Mental Health Professional Involvement is an Eligibility Requirement for Triadic Therapy During Adolescence. To be eligible for the implementation of the real life experience or hormone therapy, the mental health professional should be involved with the patient and family for a minimum of six months. To be eligible for the recommendation of genital reconstructive surgery or mastectomy, the mental health professional should be integrally involved with the adolescent and the family for at least eighteen months. While the number of sessions during these six and eighteen month periods rests upon the clinician's judgment, the intent is that hormones and surgery be thoughtfully and recurrently considered over time.
School-aged persons with gender identity disorders often are so uncomfortable due to negative peer interactions and a felt incapacity to participate in the roles of their biologic sex that they refuse to attend school. Mental health professionals should be prepared to work collaboratively with school personnel to find ways to continue the educational and social development of their patients.
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